UCLA School of Dentistry
Postgraduate Periodontal Program

California Continuing Education Credits: 3 units

Case Presentations: Case 4

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• Patient Profile
• Chief Complaint
• Medical History
• Family History
• Social History
• Dental History
• Clinical Examination
• Radiographic Examination
• Diagnosis
• Prognosis
• Treatment Plan

  Consultation:

  1. prosthodontics
  2. orthodontics
  3. oral surgery for the impacted 3rd molars
  4. endodontics

  Svstemic phase: None.

  Emergency phase: None.

  Treatment plan:

  

  PHASE 1: Preparatorv phase.
  1. Patient education
  2. Oral hygiene instruction
  3. Root Planing full mouth under local anesthesia
  4. Caries control
  5. Occlusal adjustment to eliminate balancing interferences & Fremitus
  
  Reevaluation:

  PHASE II: Surgical phase

  1. Presurgery oral hygiene level 90 % plaque free
  2. Maxillary right sextant: Combined resective and regenerative procedure (using Demineralized Freeze- Dried Bone with autogenous bone) .
  3. Maxillary anterior: Extraction of #s 7,9 with ridge and papillae preservation
  4. Maxillary left sextant: Full thickness flap with osseous resection; apicoectomy # 1 1.
  5. Mandibular anterior: Open flap debridement.
  6. Mandibular left sextant: Full thickness flap with osseous resection

  PHASE III: Corrective phase

  Maxillary:
  1. Fixed Partial Dentition #s 6-(7)-8-(9)-10-11 or
     Single tooth implants #s 7,9 or
     maxillary RPD
  and restorative treatment (with endodontic and/ or further periodontic therapies) as needed

  Mandibular:

  1. Full arch orthodontic treatment
  and restorative treatment as needed

  A occlusal splint will be provided for the patient

  PHASE IV: Maintenance phase

  1. three month supportive periodontal treatment
  2. Annual prosthetic recall
  3. plaque and calculus removal
  4. Localized Root Planing using local anesthesia for recurrent pockets
  
  Surgical Phase
  

  A. Mandibular Anterior Sextant Procedure:

  Pre-Surgical Chemotherapeutic Regimen:
  
  1. Patient rinses with chlorhexidine mouth rinse for 30 seconds before surgical procedure.
  2. Local anesthesia provided by 2% Lidocaine 1 :100,000 epinephrine initial block supplemented by local inftltration or local infiltration only, for added analgesia and hemostasis as needed
  

  Procedure: Open flap debridement
  The goal of this procedure is:

  • access the root surfaces for meticulous instrumentation
  • remove pocket lining
  • minimal recession desired
  Surgical sextant Analvsis: Adequate zone of keratinized tissue, crowded teeth.
  Surgical Plan:
  • Facial:Intrasulcular incision to preserve keratinized tissue, to allow the access to the root surface for root planning and to the alveolar housing for degranulation. Minimal bone exposure.
  • Lingual: Intrasulcular incision to preserve gingival tissue for adequate closure.
  • The surgical site was completely debrided of granulation tissue using surgical curettes. The root surfaces were carefully instrumented with curettes and ultrasonic instrumentation to be
  • clinically free of accretions. Bone architecture is not corrected. Continuous sling sutures were completed using 4.0 silk. Coe Pak periodontal dressing were placed.
  Healing:
  • I week: Dressing and sutures were removed. Wound was debrided gently with sterile saline. Patient was instructed to use a cotton swab soaked in Chlorhexidine for plaque removal.
  • 2 weeks: Healing was progressing well.
  • 6 months: Pink, firm gingiva, which exhibits no bleeding on probing. Flat or concave interproximal soft tissues were present after this procedure.

  B. Maxillary Anterior Sextant

  
  
  Procedure: Surgical extraction of #7, 9; Ridge and papillae preservation
  Surgical sextant analysis: There is adequate amount of keratinized tissue present. Severe alveolar bone loss was seen on the radiograph.
  The goal of this procedure is:
  • preservation of the alveolar ridge in horizontal and vertical dimension after extraction of #7, 9; preservation of papillae.
  Surgical Plan:
  • Intrasulcular incision around #7 and 9 with no fracture of glucoles by removal of #7 and #9 by using extraction forceps to rotate teeth.
  • #7, and 9 were extracted with preservation of the buccal plate of alveolar ridge. Gelform were condensed into small pieces and placed into the extraction sockets. Pressure was applied to the
  • buccal and palatal for 3 minutes and the areas were closed with Dexon sutures. Provisional Removable Partial Denture was inserted immediately. Patient was demonstrated to use a cotton swab soaked in Chlorhexidine to maintain optimal oral hygiene in the surgerized areas.
  Healing:
  • 1 week: Normal uneventful healing
  • 3 weeks: Extraction sites were completely closed with preservation of most horizontal and vertical dimension.
  • 4 months: Pink, firm tissue at the sites of #s 7, 9 with preservation of papillae between #8 and #9
  
  
  

  C. Upper right Sextant

  
  
  Procedure: Combined osseous resective and regenerative procedure (using Demineralized Freeze- Dried Bone with autogenous bone)
  The Goal of this procedure is:
  • access to root surfaces for debridement
  • reduce probing depths
  • ease of maintenance
  • assess prognosis for #4
  Surgical Sextant Analvsis: Adequate zone of keratinized tissue.
  Surgical Plan:
  • Buccal: Full thickness flap with intrasulcular incision and vertical releasing incision distal of #5
  • Palatal: Full thickness flap with intrasulcular incision with vertical releasing mesia] of #5. The surgical site was completely debrided of granulation tissue using surgical curettes. Scaling and root planing. A circumferential defect was found palatal to # 4 with more than 3mm vertical component and a narrow 3-wall defect at the apex. Irregular marginal bone was found on the buccal with negative architectures .
    Decalcified Freeze Dried Bone material mixed with some autogenous bone and tetracycline was condensed into the bony defect. Perio-Glass was placed over the DFDB mixed material. Interrupted sutures were used for closure with 4.0 silk, Periodontal dressing placed.

  

  Healing:
  • I week: Dressing and sutures removed. Healing well
    
  • 2 weeks: Healing was progressing well
    
  • 5 months: Slight recession lingual of # 4
    
  
  
  

  D. Mandibular left Sextant

  
  
  Procedure: Full thickness flap with osseous resection
  The goal of this procedure:
  • assess #19 for prognosis, access root surfaces for debridement
  • reduce probing depths
  Surgical sextant Analvsis: Adequate zone of keratinized tissue, large embrasure space between #18 and #19.

  Surgical Plan:

  • Facial: Full thickness flap with intrasulcular incision using papilla preservation technique to preserve the papilla between # 18 and 19; vertical releasing incision mesial of #20.
  • Lingual: Intrasulculor incision with horizontal incision between #18 and #19 The surgical site was completely debrided of granulation tissue using surgical curettes. The tooth surfaces were carefully instrumented with sharp curettes, ultrasonic instrumentation and finishing burs to be clinically free of accretions. A two- wall defect was found between # 18 and #19. Buccal and Lingual furcation were closed. This defect was broad buccal-lingually and shallow vertically. Bone was ramped to the buccal and lingual . The osseous resection technique was employed, the steps were followed: vertical grooving, radicular blending, flattening interproximal bone and gradualizing marginal bone. The exposure of furcations during osseous surgery was avoided. A vertical mattress suture were used to close the papilla between #18, 19.

  

  Healing:
  • I week: Dressing and suture were removed. Wound was debrided gently with sterile saline.
  • 2 weeks: Healing was progressing well.
  • 3 months: Pink, firm gingiva.
  
  
  

  E. Upper Left Sextant

  Procedure: Full thickness flap with osseous resection; apicoectomy #11.
  Surgical Sextant Analvsis:Adequate zone of keratinized tissue, Gingival recession #11, 12 and 13
  Surgical Plan:
  I. #11 apicoectomy
  
  • Facial: Intrasulcular incision. Vertical releasing incision M and D #11 to allow adequate access. Apicoectomy was completed. Facial flap was released further apically by split dissection to enable coronal repositioning of flap
  II. Osseous resective surgery #12-15
  • Facial: Intrasulcular incision full thickness flap raised.
    
  • Lingual: Full thickness flop.
    The surgical site was completely debrided of granulation tissue. Class II furcation was found M #14. A palatal approach was utilized to remove osseous defect. Reshaped the palatal flap to have better adaptation and exposed the M furcation of # 14 for oral hygiene. Sutured with 4.0 silk. Periodontal dressing was placed.
  Healing:
  • I week: Dressing and suture were removed.
  • 2 weeks: Healing was progressing. Mesal furcation of #14 kept open for patient's oral hygiene access.
• Dental Chart